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26Th October 1999

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26Th October 1999 In this edition we review the second of the three winners of the 2012-2013 Fred Kan & Co. Prize for a meritorious dissertation in the M. Sc. (Environmental Management) course, University of Hong Kong: A review of the effect of high fluoride content of water on health and environment and the strategy adopted for its prevention and control, with special reference to India. The Editors CONTENTS ENVIRONMENTAL AND HEALTH IMPACTS OF FLOURIDE IN WATER SOURCES IN INDIA FEATURE: Page A co-winner of the 2012-2013 Fred Kan & Co. prize (HKU), Dharmshaktu Neha, has written a lengthy ENVIRONMENTAL AND and detailed dissertation focusing on strategies adopted in India to prevent or reduce harmful impacts to HEALTH IMPACTS OF human health and the natural environment from high fluoride content in potable water sources. FLOURIDE IN WATER Objectives SOURCES IN INDIA ……... 1 The stated aims of the study included: LEGISLATION DIGEST….... 4 (1) a review of fluoride levels in potable water sources in various parts of the world, with special reference to India; and (2) an evaluation of “the strategy adopted for prevention and control of the fluorosis problem in TOWN PLANNING.………… 4 India”, focusing on “18 endemic states in India with high fluoride levels in the drinking waters…”. WEST KOWLOON Study background CULTURAL DISTRICT (WKCD)…...………………… 6 The dissertation begins with a summary of various studies and publications related to the proposition that excessive levels of fluoride in drinking water are likely to have an adverse effect on human health, plants and animals. HONG KONG BRIEFING..... 6 In relation to India, the author begins with the observation that: ADVISORY COUNCIL ON THE ENVIRONMENT “Currently in India, there are 230 districts in 18 states and union territories, which have been confirmed to be endemic for fluorosis (Susheela, 2002). Within these endemic districts, 66 million people have (ACE)………………………… 7 been identified to be at risk, while 25 million people are affected from the condition of dental fluorosis. Majority of the affected people (i.e., 6 million) are children who are less than 18 years of age. In all of CLIMATE CHANGE………. 8 these states, the drinking water has a high fluoride concentration but the information about the various food items and industrial emissions having a high fluoride level is not available. World Health REGIONAL & Organisation (WHO) guidelines (2002) suggested that in moderately hot climate, the most favourable INTERNATIONAL…………. 9 fluoride concentration in drinking water should remain less than 1 mg/L (1ppm or part per million), since during warmer climate people tend to perspire frequently and thus drinking more water. In chilly climates, people do perspire as frequently and drink comparatively lesser water. Thus, in the chillier PROSECUTION climate. The favourable fluoride concentration could reach up to 1.2 mg/L. Taking into account both of STATISTICS………………… 15 these cases, the guideline value (permissible upper limit) in drinking water was set at 1.5 mg/L, by WHO (2002). Looking at national (Indian) level of fluoride contamination, the extent ranges from 1.0 to 48 mg/L. India lowered its permissible limit to 1 pp, from 1.5 ppm in 1998 for defining contamination level in drinking water. In addition, there are significant environment contaminations with fluoride, which are associated with unprotected mines, industrial emission, coal burning, and the use of fertilizers and pesticides.” October 2014 It is also noted that when setting “guideline values for fluoride at local or international level, it is very important to consider intake from other possible routes (e.g., from air and food) and when the total intake values are found to be >6 mg/day, it is suggested to set the guideline value to <1.5 mg/L (WHO, 2006)”. It was recognised more than a decade ago that adverse impacts from fluoride was an endemic problem in 230 districts in India, yet to date administrations in only 91 districts have applied funds to addressing the problem, such as by providing filtered water supplies. Standards for fluoride levels in drinking water The author compares maximum fluoride levels allowed in various countries. For example, the standard in South Korea is 1.5 (mg/L), but in Hong Kong it is 0.5. The WHO recommendation is 1.5, but local conditions influence the standard, so there is no one general standard for all regions in the World. The most prudent approach is to monitor fluoride levels in the local water supply to look for signs of “excessive fluoride exposure in the local population”. Impact of excessive fluoride levels Twenty five countries – including the U.K., Australia, Israel and Hong Kong (China) – artificially add fluoride to drinking water supplies. Another 28 or more countries have naturally occurring fluoride in their water. The total world population exposed to fluoride is approximately 658 million. Excessive exposure to fluoride may cause dental and skeletal fluorosis in human beings. Flouride is a geogenic pollutant which can contaminate ground water aquifers and natural ecosystems. Fluorosis in India A few relevant facts about India are: it has the 7th largest land area (3.29 million square kilometres) with the 2nd highest population (1.04 billion) its population will exceed 1.33 billion by 2020 water consumption will increase by 20-40% by 2020 India possesses only 4% of the world’s water resources, to supply 16% of the world’s population Underground water reserves provide nearly 90% of drinking water Even in urban areas, only 63% of the population has access to tap water Approximately 50% of all villages face potable water scarcity. High concentrations of fluoride were first discovered in 1937 in the Nellore district of Andhra Pradesh. In the early 1930s, fluorosis was reported in only four states. Today there are 18 states with high fluoride concentrations in their aquifers. In five of these – Andhra Pradest, Haryana, Rajasthan, Maharashtra and Madhya Pradesh – the level exceeds 10mg/L. Fluorosis management in India India only recently began to tackle the fluorosis problem: “Until 2008, there was no national programme for management of fluorosis in India. In 2008 in response to the urgency of the problem of fluorosis, the NPPCF was initiated during India’s 11th Five Year Plan (2007-2012) by the Planning Commission of India (MHFW, 2009). This national initiative has been handled by the joint collaboration of different governmental and non-governmental organisations like the MHFW, the Ministry of Drinking Water and Sanitation, the Rajiv Gandhi National Drinking Water Mission (RGNDWM) and UNICEF. Presently, data regarding prevalence of fluorosis in India is based on studies conducted by different groups over a period of time (MHFW, 2009). So far, the Department of Drinking Water Supply (DDWS), Government of India has collected baseline data of households of 196 districts in 19 States/union territories (MHFW, 2009). For the provision of safe drinking water, government of India supplements the efforts of state government and union territories by providing funds under the Accelerated Rural Water Supply Programme (ARWSP) (MHFW, 2009). It was when the chairman of National Human Rights Commission and the Prime Minister’s Office reviewed the fluorosis situation in the country that a national programme for fluorosis control was recommended. The modality of the National Programme on Fluorosis falls under the supervision of the MHFW.” Several government and non-government organisations have the infrastructure to enable fluorosis diagnosis. However, generally inadequate information is available to doctors regarding fluorosis. One of the objectives of the NPPCF is the collection, assessment and use of the baseline survey data on fluorosis prepared by the DDWS. The NPPCF is currently implemented in 100 of the 196 districts with endemic fluorosis. The programme has four phases: (1) Baseline data collection, carried out in 2008-2009, following which 5 selected affected districts were given technical and education assistance to diagnose and combat fluorosis. (2) In 2009-2010, an additional 15 districts were added to the work phase described in (1). (3) In 2010-2011, 40 more districts were added to that programme. (4) In 2011-2012, another 40 districts were added, plus the programme was evaluated by an independent organisation, following which improvements to the programme were implemented. A total of 100 districts of the total 196 endemic districts were covered by the 11th Five Year Plan under the programme. Activities undertaken under the NPPCF were: (i) community diagnosis of fluorosis according to village/block/cluster; (ii) village/block/district facility mapping from prevention, health promotion, diagnostic facilities, reconstructive surgery and medical rehabilitation; (iii) gap analysis in facilities and organisation of physical and financial support for bridging these gaps, according to the strategies listed above; (iv) the diagnosis of individual cases and providing its management; and public health intervention on the basis of community diagnosis; and (v) behavioural change by way of IEC materials. Extent of fluorosis problem in India A person suffering fluorosis will have “clinical signs or symptoms of dental/ non-skeletal fluoroses along with fluoride concentrations >1mg/L in the urine”. An “endemic district” for fluorosis has “the presence of any clinical sign of dental/skeletal fluorosis as well as presence of fluoride content of above 2.5 mg/L in drinking water from 25 or more than 25 habitations”. PAGE 2 The author adopted three categories of affected districts: a. Mild Endemic District: fluoride concentration in drinking water of the district is between 1 to 3 mg/L along with presence of signs of non-skeletal fluorosis in district population; b. Moderate Endemic District: fluoride concentration in drinking water of the district is between 3.1 to 5 mg/L along with present of signs of dental fluorosis in less than 20% of the district population; c.
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